Medical Screening Lecture Notes PDF

 SCHOOL OF MEDICAL SCIENCE Medical screening DR. ISLAM ABUEMIRA PHD Of PT Cairo University. Certified Manual Therapy ( Winston Salem Uni –America) &(Mulligan -Newzelenda)&(capri -India). Certified (schroth- Germany & SEAS – Italia) for spine deformity. Certified Manual Therapy Ce...

 SCHOOL OF MEDICAL SCIENCE Medical screening DR. ISLAM ABUEMIRA PHD Of PT Cairo University. Certified Manual Therapy ( Winston Salem Uni –America) &(Mulligan -Newzelenda)&(capri -India). Certified (schroth- Germany & SEAS – Italia) for spine deformity. Certified Manual Therapy Certified Sports Injury ER (Uk)  Pelvic and abdominal visceral disorders SCHOOL OF MEDICAL SCIENCE What is the difference between a yellow- and a red-flag symptom? A yellow flag is a cautionary or warning symptom that signals, "Slow down, and think about the need for screening." A red flag symptom requires immediate attention, either to pursue further screening questions or tests, or to make an appropriate referral. The presence of a single yellow or red flag is not usually cause for immediate medical attention. Each cautionary or warning flag must be viewed in the context of the whole person, given his or her age, gender, past medical history, and current clinical presentation. 9. What are the major decision-making tools used in the screening process? Past medical history, risk factor assessment, clinical presentation (including pain types and pain patterns), associated signs and symptoms, review of systems. Each client can be framed by these five components. Any suspicious finding orresponse in any of these areas The Chest and Back (Thorax) A screening examination of the thorax requires the same basic techniques of inspection, palpation, and auscultation. Chest and Back: Inspection Clinical inspection of the chest and back encompasses both the cardiac and pulmonary systems, but some of the most obvious changes are observed in relation to the respiratory system CLINICAL INSPECTION OF THE RESPIRATORY SYSTEM Respiratory rate, depth, and effort of Prolonged expiration breathing Pursed-lip breathing Tachypnea Wheezing Dyspnea Rhonchi Gasping respirations Crackles (formerly called Breathing pattern or sounds rales) Cheyne-Stokes respiration Cyanosis Hyperventilation or hypoventilation Pallor or redness of skin Kussmaul’s respiration during activity Lateral-costal breathing Paradoxic breathing CLINICAL INSPECTION OF THE RESPIRATORY SYSTEM Use of accessory muscles Clubbing (toes, fingers) Nasal flaring Nicotine stains on fingers and Tracheal tug hands Chest wall shape and deformity Retraction of intercostal, Barrel chest supraclavicular, or suprasternal Pectus excavatum spaces. Pectus carinatum Sputum: clear or white Kyphosis (normal); frothy; red-tinged, Scoliosis green, or yellow (pathologic) Cough Chest and Back: Palpation Palpation of the thorax is usually combined with inspection to save time. Lymph node assessment may be a part of the chest examination in males and females Palpation can reveal skin changes. Look for crepitus, a crackly, crinkly sensation in the subcutaneous tissue.  Chest and Back: Palpation Assess respiratory excursion and symmetry with the client in the sitting position Assess respiratory excursion at more than one level, front to back. Bone tenderness over the lumbar spinous processes is a red- flag symptom for osseous disorders, such as fracture, infection, or neoplasm, and requires a more complete evaluation. Chest and Back: Percussion Identify the left ventricular border of the heart and the depth of diaphragmatic excursion in the upper abdomen during breathing. Percussion can also help identify disorders that impair lung ventilation such as stomach distention, hemothorax, lung consolidation, and pneumothorax. Chest and Back: Percussion Dullness over the lungs during percussion may indicate a mass or consolidation (e.g., pneumonia). Hyperresonance over the lungs may indicate hyperinflated or emphysemic lungs. Decreased diaphragmatic excursion on one side occurs with pleural effusion, diaphragmatic (phrenic nerve) paralysis, tension pneumothorax, stomach distention (left side), hepatomegaly (right side), or atelectasis. Clients with COPD often have decreased excursion bilaterally as a result of a hyperinflated chest depressing the diaphragm. Chest and Back: Lung Auscultation During the examination, the therapist should listen for normal breath sounds and air movement through the lungs during inspiration and expiration. With practice and training, the therapist can identify the most common abnormal sounds heard in clients with pulmonary involvement: crackles, wheezing, and pleural friction rub. Chest and Back: Heart Auscultation The general principles for auscultation of lung sounds apply to auscultation of heart sounds. The therapist’s primary responsibility during the screening is to know what “normal” heart sounds are like and report any changes (absence of normal sounds or presence of additional sounds). Chest and Back: Heart Auscultation The normal cardiac cycle correlates with the direction of blood flow and consists of two phases: systole (ventricles contract and eject blood) and diastole (ventricles relax and atria contract to move blood into the ventricles and fill the coronary arteries). The decision to refer a client for further evaluation is based on history, age, risk factors, presence of pregnancy, clinical findings, client distress, vital signs, and any associated signs and symptoms observed or reported. Screening of Breast Cancer The goal of screening is early detection of breast cancer. Breast cancers that are detected because they are causing symptoms tend to be relatively larger and are more likely to have spread beyond the breast. Screening of Breast Cancer The size of a breast neoplasm and how far it has spread are the most important factors in predicting the prognosis for anyone with this disease. According to the American Cancer Society (ACS) early detection tests for breast cancer saves many thousands of lives each year.  Abdomen Anyone presenting with primary pain patterns from pathology of the abdominal organs will likely see a physician rather than a physical therapist. abdominal and visceral assessment is not generally a part of the physical therapy evaluation. When the therapist suspects referred pain from the viscera to the musculoskeletal system. Abdomen: Inspection The abdomen is divided into four quadrants centered on the umbilicus (as shown in Figs. 4.48 and 4.49). During the inspection, any abdominal scars (and associated history) should be identified. Note the color of the skin and the presence and location of any scars, striae from pregnancy or weight gain/ loss, petechiae, Abdomen: Inspection From a seated position next to the client, note the contour of the abdomen and look for any asymmetry. Repeat the same visual inspection while standing behind the client’s head. Generalized distention can accompany gas, whereas local bulges may occur with a distended bladder or hernia. Abdomen: Auscultation the therapist may auscultate the four abdominal quadrants for the presence of abdominal sounds. Auscultation should occur before palpation and/or percussion to avoid altering bowel sounds. The absence of sounds or very few sounds in any or all of the quadrants is a red flag. most common in the older adult with multiple risk factors such as recent abdominal, back, or pelvic surgery and the use of narcotics or other medications. Abdomen: Percussion and Palpation Percussion over normal, healthy abdominal organs is an advanced skill, even among doctors and nurses. Palpation (light and deep) of all four abdominal quadrants is a separate skill used to assess for temperature changes, tenderness, and large masses. Keep in mind that even a skilled clinician will not be able to palpate abdominal organs in an obese person.  When palpation is carried out 1. always explain to your client what test you are going to perform and why. 2. Make sure the person being examined has an empty bladder. 3. Examine any painful areas last. 4. Use proper draping and warm your hands.  When palpation is carried out 5. Have the client bend the knees with the feet flat on the examination table to put the abdominal muscles in a relaxed position. 6. During palpation, if the person is ticklish or tense, place his or her hand on top of your palpating hand. 7. Ask him or her to breathe in and out slowly and regularly. The tickle response disappears in the presence of a truly acute abdomen  Aortic Bifurcation It may be necessary to assess for an abdominal aneurysm, especially in the older client with back pain and/or who reports a pulsing or pounding sensation in the abdomen during increased activity or while in the supine position. Abdominal aneurysm  Abdominal aneurysm Throbbing pain that increases with exertion and is accompanied by a sensation of a heartbeat when lying down and of a palpable pulsating abdominal mass requires immediate medical attention. Remember, the presence of an abdominal bruit accompanied by risk factors for an aortic aneurysm may be a contraindication to abdominal palpation. When conducting a general review of systems, ask the client about the presence of any other problems anywhere else in the body. Depending on the client’s answer you may want to prompt him or her about any of the following common signs and symptoms* associated with each system: General Questions ___Fever, chills, sweating (constitutional symptoms) ___Appetite loss, nausea, vomiting (constitutional symptoms) ___Fatigue, malaise, weakness (constitutional symptoms) ___Excessive, unexplained weight gain or loss ___Vital signs: blood pressure, temperature, pulse, respirations, pain, walking speed ___Insomnia ___Irritability  REVIEW OF SYSTEMS When conducting a general review of systems, ask the client about the presence of any other problems anywhere else in the body. Depending on the client’s answer you may want to prompt him or her about any of the following common signs and symptoms* associated with each system: General Questions ___Fever, chills, sweating (constitutional symptoms) ___Appetite loss, nausea, vomiting (constitutional symptoms) ___Fatigue, malaise, weakness (constitutional symptoms) ___Excessive, unexplained weight gain or loss ___Vital signs: blood pressure, temperature, pulse, respirations, pain, walking speed ___Insomnia ___Irritability ___Hoarseness or change in voice, frequent or prolonged sore throat ___Dizziness, falls Musculoskeletal/Neurologic ___Jointpain, redness, warmth, swelling, stiffness, deformity ___Frequent or severe headache ___ Change in vision or hearing ___Vertigo ___Paresthesias (numbness, tingling, “pins and needles” sensation) ___Change in muscle tone ___Weakness; atrophy ___Abnormal deep tendon (or other) reflexes ___Problems with coordination or balance; falling ___Involuntary movements; tremors ___Radicular pain ___Seizure or loss of consciousness ___Memory loss ___Paralysis ___Mood swings; hallucinations Rheumatologic ___Presence/location of joint swelling ___Muscle pain, weakness ___Skin rashes ___Reaction to sunlight ___Raynaud’s phenomenon ___Change in nail beds Gastrointestinal Abdominal pain ___ ___Indigestion; heartburn ___Difficulty in swallowing ___Nausea/vomiting; loss of appetite ___Diarrhea or constipation ___Change in stools; change in bowel habits ___Fecal incontinence ___Rectal bleeding; blood in stool; blood in vomit ___Skin rash followed by joint pain (Crohn’s disease) Gynecologic ___Irregular menses, amenorrhea, menopause ___Pain with menses or intercourse ___Vaginal discharge, vaginal itching ___Surgical procedures ___Pregnancy, birth, miscarriage, and abortion histories ___Spotting, bleeding, especially for the postmenopausal woman 12 months after last period (without hormone replacement therapy) Endocrine ___Change in hair and nails ___Change in appetite, unexplained weight change ___Fruity breath odor ___Temperature intolerance, hot flashes, diaphoresis (unexplained perspiration) ___Heart palpitations, tachycardia ___Headaches ___Low urine output, absence of perspiration ___Cramps ___Edema, polyuria, polydipsia, polyphagia ___Unexplained weakness, fatigue, paresthesia Hematologic ___Change in skin color or nail beds ___Bleeding: nose, gums, easy bruising, melena ___Hemarthrosis, muscle hemorrhage, hematoma ___Fatigue, dyspnea, weakness ___Rapid pulse, palpitations ___Confusion, irritability ___Headache Genitourinary ___Reduced stream, decreased output ___Burning or bleeding during urination; change in urine color ___Urinary incontinence, dribbling ___Impotence, pain with intercourse ___Hesitation, urgency ___Nocturia, frequency ___Dysuria (painful or difficult urination) ___Testicular pain or swelling ___Genital lesions ___Penile or vaginal discharge ___Impotence (males) or other sexual difficulty (males or females) ___Infertility (males or females) ___Flank pain  Precautions/Contraindications to Therapy Resting heart rate 120 to 130 bpm Resting systolic pressure 180 to 200 mm Hg Resting diastolic pressure 105 to 110 mm Hg Marked dyspnea Loss of palpable pulse or irregular pulse with symptoms of dizziness, nausea, or SOB Anemic individuals may demonstrate an increased normal resting pulse rate that should be monitored during exercise. KEY POINTS TO REMEMBER 1. / A head-to-toe complete physical assessment is an advanced clinical skill and challenge even to the most skilled physician, physician assistant, or nurse practitioner. The therapist conducts a screening assessment using appropriate portions of the physical assessment. 2. / The therapist carries out certain portions of the physical assessment with every client by observing general health and nutrition, mental status, mood or affect skin and body contours, mobility, and function. 3. / The therapist conducts a formal screening examination using the subjective and objective portions of the evaluation whenever the client history, age, gender, or other risk factors, or clinical presentation raise yellow or red warning flags. KEY POINTS TO REMEMBER 4. / Measuring vital signs is a key component of the screening assessment. Vital signs, observations, and reported associated signs and symptoms are among the best screening tools available to the therapist. These same parameters can be used plan and progress safe and effective exercise programs for clients who have true neuromuscular or musculoskeletal problems, but who also have other health concerns or comorbidities. 5. / Documentation of physical findings is important. From a legal point of view, if it is not documented, it was not assessed. Record important normal and abnormal findings. KEY POINTS TO REMEMBER 6. / The therapist must be able to recognize normal and abnormal results when conducting inspection, palpation, percussion, and auscultation of the chest, thorax, and abdomen. The order of these tests is important and differs from chest and thorax to abdomen. 7. / Auscultation usually follows inspection and palpation of the chest and thorax. Examination of the abdomen should be performed in this order: inspection, auscultation, and then palpation, because palpation can affect findings on auscultation. KEY POINTS TO REMEMBER 8. / The therapist should try to follow the same pattern every time to decrease the chances of missing an assessment parameter and to increase accuracy and thoroughness. 9. / Skin and nail bed assessment should be a part of every patient/client assessment. 10. / Changes in the skin and nail beds may be the first sign of inflammatory, infectious, and immunologic disorders and can occur with involvement of a variety of organs. KEY POINTS TO REMEMBER 11. / Consider all integumentary and nail bed findings in relation to the client's age, ethnicity, occupation, and general health. When analyzing any signs and symptoms present, assess if this is a problem with the integumentary system versus an integumentary response to a systemic problem. 12. / The therapist may encounter enlarged or palpable lymph nodes. Keep in mind the therapist cannot know what the underlying pathology may be when lymph nodes are palpable and questionable. Performing a baseline assessment and reporting the findings is the important outcome of the assessment. KEY POINTS TO REMEMBER 13. / With direct and unrestricted access of consumers to physical therapists in many states and the role of physical therapists in primary care, advanced skills have become necessary. For some clients, clinical breast exam (CBE) is an appropriate assessment tool in the screening process. 14. / Properly trained, physical therapists should be considered "qualified, health care specialists" as defined by the ACS in the provision of cancer screening when the history, clinical presentation, and associated signs and symptoms point to the need for CBE. KEY POINTS TO REMEMBER 15. / When a suspicious mass is found during examination, it must be medically evaluated, even if the client reports a recent mammography was "normal." 16. / Medical referral is advised for any individual suspected of having DVT; medical consultation is advised for those with a low probability. KEY POINTS TO REMEMBER 17. / For therapists without adequate training in conducting a CBE, the screening process is confined to asking questions during the interview regarding past medical history (e.g., cancer, lactation, abscess, mastitis) and questions to identify the possibility of breast pathology as the underlying cause for back or shoulder pain and/or other symptoms.